DIABETESDM Type 1 and DM Type 2Diabetes affects 25.8 million people; accounting for 8.3% of the U.S. population http://diabetes.niddk.nih.gov/dm/pubs/statistics/#fast

http://www.nyc.gov/html/doh/html/pr2007/pr060-07.shtmlThe Yearly Toll of Diabetes in New York City

http://www.cdc.gov/obesity/data/adult.html

Risk for Diabetes Quiz: Answer yes or no I have a parent, brother, or sister with diabetes.My family background is African-American, American Indian, Asian American, Hispanic or Pacific Islander.I have had gestational diabetes or gave birth to at least one baby weighing nine pounds or more.I have pre-diabetes (FBS of 100-126).I am overweight.I am fairly inactive & exercise < 3 times per week.I have high BP.My cholesterol levels are abnormal. My LDL is > 100; my HDL is < 35; my triglyceride level is 250 or >.

Answers to Diabetes QuizIf you answered Yes to one or more questions, you are at risk for type 2 diabetes.Your chance of getting diabetes are higher if you answered Yes to three or more.

Check your levels are regular intervals and make changes in your eating and exercise habits.

PancreasIs an exocrine glandReleases digestive enzymesIs an endocrine glandBeta calls in the Islets of Langerhans Produce & secrete insulin in response to rising blood sugars

HOW GLUCOSE GETS INTO THE BLOOD STREAM:- Intestines: absorption of simple sugars- Liver: Glycogen --> glucose(glycogenolysis)- Protein catabolism(glyconeogenesis)WHAT IS GLUCOSE USED FOR?- In tissues: oxidation(CO2 + H2O + E)- In liver glycogen formed- Converted to fat- In muscles (stored as glycogen)- Excreted in urine(BS level is > 200)

What does Insulin do?Transports & metabolizes glucose for EStimulates the storage of glucose in the liver --> glycogen (Glycogenesis)Enhances the storage of fat in adipose tissueTransports amino acids & glucose into the cellsInhibits the breakdown of stored glucose, protein, & fat

FastingPancreas releases insulin+Pancreas releases Glucagon (glycogenolysis)=Constant level of BS

8-12 hrs w/o food Glyconeogenesis

TYPE 1 Diabetes Mellitus (DM)Pathophysiology:Destruction of beta cellGlucose not stored as glycogenGlycogenolysis & gluconeogenesis occur unrestrainedFat breakdown occursALL --> HYPERGLYCEMIA

TYPE 2 Diabetes Mellitus (DM)Etiology:Insulin resistanceAND/ORDecreased production of Insulin

ALL --> HYPERGLYCEMIA

DM Diagnostic Tests:

Fasting glucose level of 126 mg/dL or >

Random glucose level of 200 mg/dL or > on more than one occasion

Hemoglobin A1C > 6.5 or 7

Nursing Interventions for HyperglycemiaCheck blood sugarType 1 DM: 2-4/day

Type 2 DM: 2-3/wk One 2hr postprandial

Type 1 or 2 hospitalized:FractionalsAC & bedtimeFractionals or Sliding scale:BSInsulin dose150-1992 units200- 2494 units250-2996 units300-3498 units350-39910 units> 400Call MD

Nursing Interventions for Hyperglycemia 2. Fluids3. Airway4. Patient teaching5. Diet- CHO 50%, Protein 25%, Fat 25%, Fiber*WEIGHT CONTROL*6. Activity & exercise7. Oral meds (Type 2 only)8. Decrease stressOral meds for Type 2 DM:1. For Insulin ResistanceAntihyperglycemic agents- Glucophage, Precose, Glycet, Actos, Avandia2. For Decrease Insulin production:Hypoglycemic agents- Diabinase, Glucotrol, Micronase, Prandin

IMPAIRED INSULIN PRODUCTION: ORAL HYPOGLYCEMICSCATAGORYDRUGACTIONADESulfonylureasPrototype: glipizide (Glucotrol)

Glyburide (Miconase, DiaBeta) Insulin productionHypoglycemiaCommon: N, abd fullnessMegitinideRepaglinide (Prandin)Nateglinide (Starlix) Insulin productionHypoglycemia

DECREASE INSULIN RESISTANCE: ANTIHYPERGLYCEMICSCATEGORYDRUGACTIONADEThiazolidinedionesPioglitazone (Actos)) Insulin resistanceincidence of angina, MIBiguanidePrototype: metformin (Glucophage) Insulin resistance, hepatic glucose prodBlack box: lactic acidosisCommon: N, V, abd discomfortAlpha-Glucosidase InhibitorsMiglitol (Glyset)Acarbose (Precose)Delays GI absorption of glucoseAbd discomfort, D, flatulence

Things to know about Insulin

TIME

AGENT

ONSET

PEAK

DURAT

INDICA.

Rapid acting

(clear)

Humalog

(Lispro)

10-15min

1 h

3 h

-rapid reduction of BS

Short acting

(clear)

Regular

R

1/2-1 h

2-3 h

4-6 h

Give 20-30 min ac

Intermediate

acting

(cloudy)

- NPH

Humulin N

- Lente Humulin L

3-4 h

4-12 h

16-20 h

Give pc

Long acting

(cloudy)

Ultralente

UL

6-8 h

12-16 h

20-30 h

Control s

FPG

Long acting

(clear)

glargine (Lantus)

1 h

No Peak

24 h

Do NOT mix with other insulins

Things to know about InsulinIn General:70/30 Insulin: 70% NPH & 30% RegularRapid & short acting Insulin cover meals immediately AFTER the injectionIntermediate acting Insulin is expected to cover subsequent mealsLong acting Insulin provides a relatively constant level of Insulin and act as a basal Insulin

Things to know about InsulinOnly Regular Insulin in given IV

Rotates site

Mixing types: clear to cloudy

Insulin Regimes3-4 injections/day2 injections/day1 injection/dayCONVENTIONALINTENSIVE

Things to know about InsulinInsulin Pens

Insulin Pumps

Hypoglycemia: AssessmentToo little food/ To much Insulin or DM meds/ Extra activity1. Blood sugar < 602. Nervousness, trembling3. Increase SNS4. Moist, clammy skin5. Dizziness, anxious, hunger

6. Impaired vision7. Weakness, fatigue8. Confusion, irritable, restless9. Convulsions w/ BS < 4010. Coma --> death

Hypoglycemia: Nursing InterventionsGive sugarGlucagon IVCheck VSMonitor BSOn going assessmentComatose - maintain airwayPatient education

Old Saying:Cold and clammy means you need some candyHot and dry your sugar is to high!

Classifying Hypoglycemia

MILDMODERATESEVEREConsciousConsciousUnconsciousHungerDiaphoresisTremorAnxiety or drowsinessWeaknessHeadacheBehavior changeBlurred, impaired or double visionIrritation or confusion, difficulty talkingUnresponsive unable to take oral feedingSeizure activityFood with 15 grams of carbohydrates:3 to 4 chewable glucose tablets1 tablespoon of jamI tube of glucose gel4 to 6 ounces of fruit juice4 to 6 ounces of regular soft drink3 packets of sugar or 1 tablespoon of sugar1 tablespoon of honey5 to 7 hard candies

Diabetic TestingSelf Monitoring of BSGlycosylated Hemoglobin A1CHgb A1CUrineKetonesFor Type 1 DM esp for BS>200

Correlating A1C with average BS715481839212102401126912289

DM: Complication1. Insulin Therapy2. Diabetic KetoacidosisType 1 DM

Clinical Picture:HyperglycemiaFVDAcidosisNursing Assessment:BS of 300-800Resp: rapid & deepAcidosisKetonesFVD & electrolyte loss

Medical Management DKA:InsulinHydrationNS or 0.45NSElectrolyte loss KAcidosis

Sick Day Rules for Type 1 and 2:

Take Insulin/oral meds as usualTest BS q 3-4 hrsType 1 BS > 200 test for ketonesReport BS > 300Small, freq mealsV or D: c cola, juice, or broth q hrReport N/V/D to MD

DM: Complication 3. Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS): Clinical Picture:HyperglycemiaFVDTachycardiaAlteration in Sensorium

Nursing assessment:- Type 2 DM- BS > 1,000 - RR: WNL - pH: WNL - No ketonesPrevention: Sick Day Rules

ParameterDKAHHNKDiabetesType 1Type 2Serum glucose300-800Often > 1,000Arterial pHAcidicNormalSerum ketonesPositiveNegativeUrine ketonesPositiveNegativeOnsetQuickslowlyCause: Lack of Insulin breakdown of fatsLack of enough Insulin, but enough to prevent the breakdown of fatsClinical AssessmentDry skin & mucous membranes, < skin turgor, tachycardia, hypotension, altered LOCDry skin & mucous membranes, < skin turgor, tachycardia, hypotension, altered LOCKussmauls RespRegular & shallowMortality5-30%Near 50%

DM: Complication4. MACROVASCULARCADCVDPVD

5. MICROVASCULARRetinopathyNephropathy

6. NEUORPATHIESPeripheral (sensorimotor)Autonomic: CV GIUrinary Adrenal

DIABETES INSIPIDUSA Pituitary disorderLeads to polyuria and polydipsiaTreatment:Replace fluids,I&ODiet: Hi Na & hi KAqueous vasopressin (Pitressin) or Desmorpressin (Stimate)

Metabolic Syndrome or Syndrome XCluster of risk factors:High Triglycerides: > 150Low HDL: < 40High BP: > 130/85Insulin-resistance: BS 110-125Waist:Females: > 35 inchesMales: > 40 inches

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**********. ****A black box warning is the sternest warning by the U.S. Food and Drug Administration (FDA) that a medication can carry and still remain on the market in the United States.A black box warning appears on the label of a prescription medication to alert you and your healthcare provider about any important safety concerns, such as serious side effects or life-threatening risks.

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***Question: What is the major difference between DKA and HHNS? Which one has a greater mortality rate and why?****